The following is a presentation on Ethical Considerations for Global Health, delivered on Global Health Day at the University of Minnesota, sponsored by the University's Global Health Day, Center for Global Health and Social Responsibility
November 21, 2014
I want to thank the Center for Global Health and Social Responsibility, as well as the Academic Health Center, for inviting me to join you this morning. It is indeed an honor for me to be with you.
I have to be frank -- this is an intimidating assignment for me.
Whatever background and experience I might have on issues and institutions relating to international humanitarian response -- conflicts and crises and natural disasters -- I am not a public health expert -- and, well, many if not most of you are.
So this for me is a bit of what one might call a James Stockdfale moment. For those of you who are closer to my age, you will remember that Admiral Stockdale was plucked from obscurity by Ross Perot, to serve as a vice presidential candidate in Perot's third party quest for the White House in 1992. And at an October 13, 1992 vice presidential debate, Admiral Stockdale began by stating, and I quote, "Who am I? Why am I here?"
And I can relate to that perspective.
But there is another quote from James Stockdale, a remarkable man who endured, in a truly heroic way, unspeakable mistreatment as a prisoner of war in Vietnam, that is probably more appropriate at this particular moment in history -- a moment in which the world is confronting an overwhelming international public health challenge around the Ebola virus -- and that is a Stockdale statement, reflected in a conversation with author Jim Collins, in his book, Good to Great, and known as the Stockdale Paradox:
"You must never confuse faith that you will prevail in the end -- which you can never afford to lose -- with the discipline to confront the most brutal facts of your current reality, whatever they might be."
And when Admiral Stockdale was asked by Collins about the characteristics of those prisoners of war who didn't make it out of Vietnam, he responded, "Oh, that's easy, the optimists. Oh, they were the ones who said, 'We're going to be out by Christmas.' And Christmas would come, and Christmas would go. Then they'd say, 'We're going to be out by Easter.' And Easter would come, and Easter would go. And then Thanksgiving, and then it would be Christmas again. And they died of a broken heart."
I cannot help but note the striking similarity between those sentiments of Admiral Stockdale and what I have heard in more than one speech from our colleague here at the University of Minnesota, Michael Osterholm, director of the Center for Infectious Disease Research and Policy, who has been so very active publicly on the Ebola epidemic. Dr. Osterholm has spoken out repeatedly and appropriately against undue expressions of optimism -- optimism about progress in addressing the epidemic, and optimism about the knowledge we have about what is needed to put an end to the losses of human life.
And if this is the most critical public health crisis of our time, it also presents the most compelling ethical challenges for governments, international organizations and international NGOs.
So how does one think about ethics, notions of right and wrong, in the context of what the world ought to be doing on the Ebola crisis?
It seems to me that a reasonable starting point might be principles, or norms for action that already reflect a degree of international consensus.
And if there are such principles that are on some level broadly accepted, the basic ethical question is rather simple: are we acting with integrity with respect to those principles -- are we practicing what we -- governments of the world and international organizations -- have been preaching broadly?
So let's look at some of those basic principles.
One emerges from a social phenomenon described in a recent comment by Jim Yong Kim, the president of the World Bank, who said that "thousands of people in these countries are dying because, in the lottery of birth, they were born in the wrong place."
Commenting on Kim's statement, the writer and social critic Leon Wieseltier lamented that "no course of action can any longer dispel the spectacular sense of the unfairness of life." In a New Republic piece, he went on to write that "[w]e must not hold a view of the world that cannot include all the people in all the countries, including our own, who persevere under the sway of accident. They are not responsible for their suffering. If the discovery of their suffering is a reason for desolation, it is also a reason for kindness."
Fair enough -- kindness is so critical. But in this case, the discovery of this terrible suffering is more than a reason for kindness, as kindness is usually an act of choice, of discretion -- it is akin to charity.
But in fact, governments of the world have gone beyond recognizing the injustice of the lottery of birth and the importance of kindness, and have accepted the basic principle of humanity -- the idea, as articulated by the UN's Office for the Coordination of Humanitarian Affairs, that --
"Human suffering must be addressed wherever it is found" -- wherever it is found, and that "[t]he purpose of humanitarian action is to protect life and health and ensure respect for human beings."
Humanity as a basic principle of humanitarian response pushes back against the notion of a lottery of birth. And this principle, articulated in an important and systemic way some 50 years ago by the International Committee of the Red Cross, has been endorsed by governments of the world. For example, it is reflected in the 1991 UN General Assembly resolution that gave rise to the current public international system of humanitarian response and in the "Good Humanitarian Donorship Initiative," a statement of principles endorsed by the world's major donors.
And the principle is also reflected in broadly accepted human rights documents, such as the International Covenant on Economic, Social and Cultural Rights, which charges states to take action necessary for the prevention, treatment and control of epidemic diseases.
So when we think about judging the adequacy and the strength of the Ebola response, this is the frame we ought to be using.
Far be it from me to suggest that a nation-state cannot claim a greater obligation to its own citizens than to citizens in places thousands of miles away.
But when we consider issues like the huge disparities between per capita resources devoted to Ebola response in the United States and those devoted to response in Africa; when we consider whether President Obama's $6.2 billion supplemental Ebola assistance request, as large as it is, is adequate, or whether the response by Congress is sufficiently prompt, we ought not look at the issues -- or not look at them solely -- through the lens of whether or not we are exercising kindness, or whether or not we are being charitable, but rather, whether we are acting within the dictates of principles of humanity to which our government and others in the international community have subscribed.
Let me now move to a second issue which has occupied a great deal of the concern, time and attention of the international community -- and that is the speed and adequacy of the response.
While experts are fairly making the case that efforts to suppress the epidemic, in and of themselves, will not be enough to resolve this crisis -- and that an Ebola vaccine must be the ultimate objective -- all appreciate the need for swift action.
Of course, in the Ebola case, governments of the world and international organizations failed to anticipate adequately the magnitude of the crisis -- the French medical organization, Doctors without Borders, was sounding the alarm as early as last winter. But at this point, there is little to do but play catch up. And of course, if you are playing catch up, you have a compelling obligation to act with speed, with resources, and with a dedication to ensure that rhetoric about the timeliness and magnitude of response meets reality.
This is so important, as the international humanitarian landscape has too many examples of expressions of commitment to act that were not matched by actions that met those commitments. And when that occurs, the results can be disappointing and dangerous: not only a failure to address suffering, but the creation of expectations that will not be met and the development of complacency among those who are in a position to help, further heightening risks and exacerbating human tragedy.
On this score, there are some encouraging signals, but also much about which to be deeply concerned.
First, the United Nations has created the first ever system wide UN emergency health mission, reflecting an effort to develop -- to use the UN Secretary General's words -- "the operational framework and unity of purpose to ensure the rapid, effective and coherent action necessary to stop the outbreak, to treat the infected, to ensure essential services, to preserve stability and to prevent the spread to countries currently unaffected."
The mission is based in Ghana, under the authority of a Special Representative of the Secretary General, with Crisis Managers and teams in Liberia, Guinea and Sierra Leone, and it aspires to a unified chain of command, with the variety of UN agencies which usually operate quite independently reporting in this instance to the UN mission. If this actually occurs, it will help to ensure that dual mission objectives, of serving as a crisis manager and filling any and all gaps in response that arise, will be achieved.
Here again, the necessary response is also the one that largely reflects principles to which countries of the world have already subscribed -- including through formal admonitions by governments to the United Nations about its responsibilities to ensure the prompt delivery of humanitarian aid. And of course, the United Nations is not an entity that is separate from member states, but rather is composed of those very member states that have endorsed the principles of prompt and effective aid. And the United Nations Ebola mission -- and the UN Secretariat generally -- will only be effective if member states come forward promptly and generously.
But while the United States and some other major donors have made significant and substantial responses, the effort is falling short. Yesterday's New York Times report about agency infighting in Liberia, although not shocking to those who are aware of management challenges in international organizational response, was nonetheless disheartening. And while the ONE Campaign's donor tracker of some 19 major donor countries, international organizations and NGOs identifies about $3 billion in commitments of aid, it also reveals that the bulk of those commitments have yet to be disbursed; and that commitment is only about a third of the yet-to-be appropriated $6.2 billion request that the Obama administration has pending before the Congress. Finally, Oxfam earlier this month complained loudly that nearly half of the G20 countries had failed to deliver in the global effort to defeat the Ebola virus.
So here again, it is time for governments of the world to do more to practice what they preach about both the timeliness and adequacy of response.
Finally, I want to consider a third principle that has been endorsed by governments of the world: the principle of resilience. If public health systems in West Africa were not in such awful states - if there had been much greater resilience within systems -- this would have been a crisis of a far different magnitude. And resilience is not simply a function of wealth -- as reflected by the case of heath care in Cuba, whose government has in fact sent health workers to Africa to support the Ebola response.
Here my own personal experience in international humanitarian affairs, and in work at responding to disasters caused by natural hazards, very much guides my thinking. In the Clinton Administration, we dealt with the devastation of Hurricane Mitch in Central America. As the UN's Deputy Envoy for Tsunami Recovery, I was deeply involved in a multi-nation recovery effort in Asia. And as an official in the Obama administration, I assisted in recovery efforts following the 2010 Haitian earthquake.
And what became so obvious in those efforts was that in the case of earthquakes, hurricanes and even tsunamis, the very same hazards that cause inconveniences in societies that have addressed issues of prevention can cause death and destruction of staggering proportions in those societies without resilient institutions.
As it happened, the 2004 Asian tsunami, which took the lives of well over 200,000 people in Asia, occurred just prior to a long-scheduled 2005 meeting on international disaster prevention held in Hyogo, Japan, and transformed that meeting into a major international event that spurred efforts at creating resilient institutions -- with a focus on education programs, building codes, national plans of action, early warning, and on and on. And the final document from that conference, the Hyogo Framework for Action, has served as an important resilience guidepost for the international community ever since.
The parallel to international public health is clear and compelling.
This concept of resilience in public health is hardly new. At the same time, much of the normative conversation internationally about the imperative of public health has involved the human right to health care. There is a WHO webpage on the right to health, and it mentions not only the International Covenant on Economic, Social and Cultural Rights, but the European Social Charter, the African Charter on Human and People's Rights, and other international and regional instruments.
I certainly have no objection to the articulation of these goals in terms of rights, but I also hope that this crisis will move the international community on issues of health in a way that the Asian tsunami moved governments on disaster risk reduction -- and toward greater acceptance of principles, norms and action around resilience.
That, it seems to me, would be one positive outcome to this terrible tragedy.
In conclusion, allow me to go back to Leon Weiseltier, whose piece in the New Republic on Ebola was inspired by a report in the New York Times by Adam Nossiter, entitled "A Hospital from Hell, in a City Swamped by Ebola."
Weiseltier, noting he did not recall ever being so shattered by a piece of journalism, refers to a four year old girl, lying "on the floor in urine, motionless, bleeding from her mouth, her eyes open. A corpse lay in the corner -- a young woman, legs akimbo, who had died overnight. A small child stood on a cot watching as the team took the body away, stepping around a little boy lying immobile next to black buckets of vomit. They sprayed the body, and the little girl on the floor, with chlorine as they left."
Again, the piece ends with Wieseltier's plea for kindness.
One should certainly embrace this plea for kindness.
But the ethical imperative for action goes beyond kindness; I believe it reaches obligations to the principles of humanity, to prompt and robust humanitarian response, and to resilience. Action on these imperatives creates the prospect for a brighter future for millions of people in Africa and around the world.